A nurse is assessing a client who is receiving intravenous therapy. The nurse should identify which of the following findings as a manifestation of fluid volume excess?

Choice A Reason:
Nausea is incorrect. Nausea is a common side effect of many medications, including antibiotics like amoxicillin. While it can be a side effect of an allergic reaction, it's also a general symptom that can occur due to various reasons, such as gastrointestinal upset or the direct effects of the antibiotic on the stomach lining. Nausea alone is less specific for indicating an allergic reaction compared to severe symptoms like laryngeal edema.
Choice B Reason:
Insomnia is incorrect. Insomnia, or difficulty sleeping, is not a typical manifestation of an allergic reaction to amoxicillin. Allergic reactions usually involve more immediate and visible symptoms such as skin rash, itching, swelling, difficulty breathing, or in severe cases, anaphylaxis. Insomnia is not a common symptom associated with allergic responses to antibiotics.
Choice C Reason:
Laryngeal edema is correct. Laryngeal edema, or swelling of the larynx, is a serious symptom of an allergic reaction known as anaphylaxis. This severe allergic reaction can be life-threatening due to its potential to obstruct the airway, leading to breathing difficulties.
Choice D Reason:
Cardiac dysrhythmia is incorrect. While medications can sometimes affect heart rhythms, cardiac dysrhythmia is not a common symptom of an allergic reaction to amoxicillin. Allergic reactions tend to manifest with more immediate symptoms like skin reactions, respiratory issues, or swelling rather than primarily affecting the heart rhythm.

Choice A Reason:
Contact the provider to clarify the prescription is not appropriate. Contacting the provider might not be necessary in this case. The prescription specifies "NOW," indicating an urgent administration, which is a clear directive to administer the medication promptly without further clarification.
Choice B Reason:
Administer the medication within 90 minutes is appropriate. "NOW" typically implies an urgent need for administration, and within a hospital setting, "NOW" often indicates a timeframe of around 90 minutes for prompt administration of the medication.
Choice C Reason:
Notify the pharmacy to send the medication immediately is inappropriate. With the prescription stating "NOW," the need for immediate administration usually requires using the hospital's available stock of the medication rather than waiting for delivery from the pharmacy. This action might cause a delay in administration.
Choice D Reason:
Inform the client there is a prescription available if needed is inappropriate. This option is not suitable in this scenario. "NOW" in the prescription implies the immediate need for administration, so informing the client about the availability of the prescription doesn't align with the urgency implied by the directive "NOW."